December 1, 2013
2013 marked the 32nd year since the first published reports of what we now know as the "human immunodeficiency virus." HIV/AIDS has exacted a devastating toll across the globe since the first reported cases. But there has been substantial progress and some of that was seen this year in the United States. The government has expanded access to health insurance, there have been substantial advances in biomedical prevention, vaccine research and medications ... and there is some hope for a "cure."
But many obstacles remain toward eliminating the domestic epidemic. New infections are rising among men who have sex with men, especially gay and bisexual men of color. Meanwhile, pervasive stigma and the criminalization of HIV are daily reminders of how much more work must be done before we see "zero new infections."
Let's take a look at some of the leading HIV/AIDS stories in the past year ...
The Affordable Care Act Broadens Coverage
The Patient Protection and Affordable Care Act represents the most significant overhaul of the U.S. health care system since the passage of Medicaid and Medicare in 1965. Open enrollment began on Oct. 1 and the program remains a historic legislative step in the fight against HIV/AIDS.
The ACA will offer broader health care coverage to many Americans infected with HIV. Currently, fewer than one in five of the 1.1 million people living with HIV/AIDS (PLWHA) in the U.S. have private insurance and nearly 30 percent do not have any coverage. The new law will deny discrimination based on pre-existing conditions such as HIV/AIDS, will deny limitation of benefits and expand Medicaid coverage.
Unfortunately, an estimated 43 percent of PLWHA live in states that are not currently expanding Medicaid. Many of these states are disproportionately lower income, African American and in the South -- and these areas are where new infections are rising the fastest.
A "Cure" for AIDS?
Reports of a Mississippi infant who had been "cured" of HIV dominated news coverage during early March 2013. The infant girl was born in rural Mississippi in July 2010 to a mother who did not receive prenatal care or HIV treatment. Doctors began administering powerful antiretrovirals to the child only hours after she was born. The child remained on HIV meds for approximately 15 months before she and her mother were lost to care for more than half a year, and the little girl is now believed to be "functionally cured" -- the presence of the virus is so minute that lifelong treatment is not necessary.
The pediatric "functional cure" has renewed focus on the so-called HIV "cure" agenda. Only days after the pediatric case made international news, French investigators reported their "functional cure" of 14 patients. These follow the widely reported case of Timothy R. Brown -- the so-called "Berlin patient" -- who doctors said was "cured" of HIV via a radical stem cell transplant. Researchers hope that the Mississippi and French cases will yield some broader implications for treating people living with HIV/AIDS.
Vaccine Breakthroughs and Biomedical Prevention
The past year has seen a suite of vaccine candidates in the news. Most notably, a possible "breakthrough" in the elusive quest for an HIV/AIDS vaccine was publicly presented at the AIDS Vaccine 2013 meeting in Barcelona. Oregon Health and Science University's Dr. Louis J. Picker presented data that demonstrated vaccinated monkeys could clear simian immunodeficiency virus -- the monkey equivalent of HIV -- from their bodies. The vaccine used cytomegalovirus as a platform.
Human trials could start in about two years. Vaccine trials are also moving forward in Thailand and South Africa that build on the modest success of RV144 in 2009.
On the biomedical prevention horizon: Pre-exposure prophylaxis, or PrEP, remains one of the most exciting prevention strategies in the toolbox. Daily use of Truvada has shown up to 73 percent efficacy in preventing HIV transmission among men who have sex with men in one study; another showed that HIV acquisition risk could be cut by up to 99 percent with daily dosing. New studies show that gay men are not taking more risks while using PrEP and that it is successful when used by straight couples. But questions remain around access and efficacy for women.
Criminalizing the Epidemic
The United States reportedly leads the world with "thousands" of prosecutions of people living with HIV/AIDS. Thirty-two states and two territories criminalize exposure and/or transmission of HIV. Some states penalize people for having sex without revealing their serostatus -- even if a condom was used, the person's viral load was undetectable, and even if the virus was not transmitted.
Recent years have seen a surge in prosecutions -- especially around spitting or biting cases, which pose very little risk of transmission. One of the more infamous recent cases involved a black, gay, HIV-positive Michigan man who initially faced bio-terrorism charges after he allegedly bit another man during a brawl.
Rep. Barbara Lee (D-CA) has introduced the Repeal Existing Policies that Encourage and Allow Legal HIV Discrimination Act, or REPEAL Act, for the second year in a row. That would mandate a federal review of HIV-specific discrimination laws. Sen. Chris Coons (D-Del.) introduced companion legislation last week in the Senate. Let's hope for some movement.
The Graying of HIV/AIDS -- and the Wages of Longtime Survival
By 2015, an estimated half of the 1.1 million Americans living with HIV will be older than the age of 50. A growing number of new infections are among people over 50 but the vast "majority of people aging with HIV are long-term survivors ... [of] the AIDS Generation," according to a recent report by amfAR. The aging or "graying" of the epidemic has sparked a slew of research, social service and pharmacological concerns, as well as a growing cultural awareness around long-term survivors. We Were Here and the Academy Award-nominated How to Survive a Plague are two recent documentaries that chronicled the so-called "AIDS Generation."
Early ACT UP member Spencer Cox co-founded the Medius Working Group to address HIV and aging. The group held a critically acclaimed and well-attended forum in New York City in May 2013 entitled "Is this My Beautiful Life? Perspectives from Survivors of the AIDS Generation." Tragically, the man responsible for the organization could not attend. Spencer Cox died on Dec. 18, 2012.
The week of Feb. 11, 2013, marked a bittersweet footnote in the 30-plus-year history of the domestic HIV/AIDS epidemic. The week started with President Barack Obama including "the promise of an AIDS-free generation" in his State of the Union address. The week ended as the National Association of People With AIDS ceased operations.
NAPWA was founded in 1983. It was the first and oldest voice for the 1.1 million people living with HIV/AIDS in the United States. NAPWA challenged the framing of the new disease in the dark days of the 1980s. NAPWA rejected the then-common descriptions of "AIDS victims" and embraced the term "people living with HIV/AIDS." The group also founded the first National HIV Testing Day in 1998. For many years, NAPWA was the cornerstone of the self-empowerment movement for PLWHA -- and its memory and legacy live on today.
"Alarming" Increases in HIV Cases Among Black MSM
The statistics on the epidemic in Black America are sobering. African Americans and other black communities represent only 14 percent of the nation's population but account for nearly half -- some 44 percent -- of all new HIV infections.
Black men who have sex with men experience the highest new infection rates in the country. New infections among young black MSM ages 13 to 19 soared by 48 percent between 2006 and 2009 -- an "alarming" increase according to the U.S. Centers for Disease Control and Prevention (CDC). Young, positive black MSM are also among the least likely to be aware of their infection, putting their own health and others' at risk.
Many researchers and policy makers believe that it is likely a "perfect storm" of factors -- late testing, poor access to health care, risk behaviors, stigma, racism, homophobia, etc. One small study also found young black MSM to likely have older sexual partners -- and are much more likely have sex with other black men, especially within "closed" sexual networks.
Latinos and the Epidemic
The demographics of the domestic HIV/AIDS epidemic have changed as it enters its fourth decade. HIV was initially believed to be a problem for white, gay men. Now it's largely seen as a "black and brown" epidemic -- disproportionately affecting African Americans and Latinos.
Latinos have become the largest minority in the United States -- and seroconversions are also rising. Latinos represent about 16 percent of the population and about 20 percent of all new infections. They experience a wide array of health disparities: Latino men are three times as likely to be infected as compared to white men. Latinas are four times as likely to become HIV positive compared to white women. Latino men who have sex with men are also disproportionately impacted.
New interventions are being developed across the country -- especially in rural areas and the South, where new HIV cases, as well as Latino populations, are rising. Poverty, lack of access to health care and insurance, language barriers, immigration and criminalization are among the many challenges that must be addressed.
Research and Recommendations Address the Gender Divide
About one in four adults or adolescents living with an HIV/AIDS diagnosis in the United States are women, according to the CDC. Women of color, especially black and Latina women, are disproportionately affected compared to women of other races/ethnicities.
African-American women and Latinas also tend to be late testers -- and receive an AIDS diagnosis at the same time or within one year of their initial diagnosis. This means they are much less likely to benefit from antiretroviral therapy. Women also experience a wide range of symptoms, contraindications and gender-specific side effects, such as recurrent vaginal yeast infections, severe pelvic inflammatory disease, menstrual changes, menopause complications and more ... and of course, prenatal and reproductive concerns. Black and Latina transgender women are also severely impacted. Infections are decreasing among black women -- but many Latinas and black women continue to press for increased funding to address the epidemic among them.
Some good news: In the past year, more research has been published that addresses the intersections of gender-based violence, trauma and vulnerability to becoming HIV positive. The Federal Interagency Working Group on the Intersection of HIV/AIDS, Violence against Women and Girls released an important set of policy recommendations to address the health and rights of women living with HIV, especially those affected by violence. But without additional funding directed toward carrying out the working group's recommendations, what's to come of this important work remains to be seen.
Advances in Treatment
The last year has seen a number of advances in treatment and medications. Stribild, a once-daily, single-pill regimen, and Tivicay, a newly approved integrase inhibitor, are now on the list of "preferred" HIV medications in the official U.S. HIV treatment guidelines -- a recommendation that was announced on Oct. 30. Until that date, only four medications were recommended for first-line treatment: Atripla, Norvir/Reyataz/Truvada, Norvir/Prezista/Truvada and Isentress/Truvada. The changes highlight "the rise of integrase inhibitors as an established, reliable family" of medications for first-line treatment, in the words of TheBody.com's Myles Helfand in a recent piece.
Also making news: On Dec. 31, 2012, the Food and Drug Administration approved Fulyzaq (crofelemer) as the first drug to relieve symptoms of diarrhea that is a side effect of HIV antiretrovirals. Current HIV medications are "aren't nearly as likely to cause diarrhea as the first generation of meds did -- but it remains a problem for many.